Medication safety and error prevention in children — formative SAQs

SAQ 1 — Immediate response and paediatric vulnerability (10 marks)

A six-month-old infant becomes apnoeic on the ward shortly after an opioid infusion is started. The nurse stops the pump. The baby is dusky but has a pulse. The order reads for a weight-based dose, but the pump was set ten times too fast. [1] [8]

Questions

1. Define medication error, adverse drug event and near miss. (3 marks) [1]
2. Outline your immediate clinical and safety actions in order. (4 marks) [13]
3. Explain why children are uniquely vulnerable to medication errors. (3 marks) [1]

Model answer

Definitions (3). A medication error is any preventable event that may cause inappropriate medication use or harm while the drug is in the clinician's or carer's control. An adverse drug event is actual harm from a medication. A near miss is an error caught before reaching the child. [1]

Immediate actions (4). Rescue the airway, breathing and circulation; give naloxone and call for senior help; keep the pump stopped and preserve the settings and syringe; isolate the order and check other children on the same protocol; document facts; tell the family an unexpected event occurred and care is focused on safety; report in the incident system. [13] [1]

Paediatric vulnerability (3). Dosing is weight-based in mg per kg, so one adult dose fragments into many paediatric possibilities and a misplaced decimal becomes a tenfold error. Neonates and infants have immature hepatic and renal function, narrowing the therapeutic window. Off-label and unlicensed use removes the safety net of an established reference dose. [1] [8]

SAQ 2 — Prevention system and strong actions (10 marks)

A PICU has recurring near misses with high-risk infusions. A root-cause analysis identifies interruption-prone drug rounds and inconsistent independent double-checks. The team wants sustainable change. [10] [14]

Questions

1. Name the five stages of the medication-use process and state which is most error-prone. (3 marks) [4]
2. Contrast strong and weak error-prevention actions, giving one example of each. (4 marks) [13]
3. Describe two system interventions to reduce administration errors in this PICU and cite the evidence. (3 marks) [10] [14]

Model answer

Medication-use process (3). The five stages are prescribing, transcribing, dispensing, administration and monitoring. Prescribing is the most error-prone stage, while administration is where harm is most often realised. [4]

Strong versus weak actions (4). Strong actions change the system — a forcing function, standard concentration, or computerised order entry with paediatric decision support that physically blocks an out-of-range dose. Weak actions rely on memory and effort — a poster campaign or a re-education session alone. For a design problem, strong actions are the answer; weak actions supplement but never substitute. [13]

Interventions (3). Minimise interruptions during medication preparation and administration — Bonafide showed nurse telephone interruptions are associated with more administration errors in a PICU. Implement a robust independent double-check for high-risk drugs and infusions — Konwinski's human-factors work shows the double-check helps only when it is independent, focused and not theatre. [10] [14]